Jacquelyn Hunt, PharmD, MS, BCPS
Executive director of quality and care improvement, Providence Physician Division, Beaverton, Ore.
Yelena Rozenfeld, MPH
Statistician at Providence Physician Division, Beaverton, Ore.
Rahul Shenolikar, BS Pharm, PhD
Manager of applied outcomes & analysis, GlaxoSmithKline, Research Triangle Park, N.C.


Type 2 diabetes is a growing epidemic, with approximately 20.8 million persons with diagnosed and undiagnosed type 2 diabetes in the United States (National Institutes of Health 2007). Diabetes-related costs in the United States are staggering and result from mortality, permanent disability, and lost productivity (Hogan 2003). Improved glycemic management, as measured by reduced glycosylated hemoglobin (A1c), can minimize the risk of diabetes complications (UKPDS 1998), lower health care costs, and increase workplace productivity (Shetty 2005, Stephens 2006, Testa 1998, Tunceli 2007, Von 2005, Wagner 2001).

Adherence to medications plays a critical role in the achievement and maintenance of glycemic control. Adherence to diabetes medication regimens has been associated with improved glycemic control and reduced health care costs (Krapek 2004, Lawrence 2006, Lee 2006, Schectman 2002, Sokol 2005, Wagner 2001). Patients’ out-of-pocket expense (cost share) has been identified as one of several factors that can influence adherence to prescribed medications (Briesacher 2007, Chernew 2008, Cole 2006, Ellis 2004, Gibson 2005, Gibson 2006a, Gibson 2006b, Zeber 2007). Research suggests that 32 percent of older adults take less medication than prescribed in order to avoid costs (Soumerai 2006).

The extent to which patient cost share affects adherence and, therefore, health outcomes is important to understand, given recent insurance trends. In response to escalating pharmaceutical costs, pharmacy benefit design has evolved to increase the portion of medication expense borne by beneficiaries. For patients enrolled in employer-sponsored health plans, copayments for prescription drugs increased significantly between 2000 and 2006, rising from $13–$24 to $17–$38 (Kaiser Family Foundation & Health Research and Educational Trust 2007). Such changes in pharmacy benefit design may have unintended effects on patients’ adherence to medications for chronic conditions. The strategy of shifting costs to patients in an attempt to combat escalating health care expenditures and patient cost-sharing as an impediment to care are topics of widespread debate (Braithwaite 2007).

For patients with diabetes, data that link patient cost share with adherence to diabetes medications and clinical outcomes are sparse. This study was undertaken to evaluate the associations between patient medication cost share and (1) adherence to oral diabetes medications and (2) glycemic control.

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.